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Found 530 results
  1. Content Article
    Repeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period.  The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
  2. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Sarah and Jaydee are working on an innovative project at NHS Dorset Integrated Care Board (ICB) to ensure general practice is a central part of improving patient safety across services. They talk about the value and challenges of collaborative working, how they are tailoring their offer to fit the needs of local GP practices, and making patient safety a core part of training for all healthcare professionals.
  3. Content Article
    Serious case reviews from the past twenty years have repeatedly highlighted the absence of professional curiosity as a core failing in the actions of health and social care professionals. However, 'professional curiosity' as a term is still not commonly used amongst healthcare professionals and there is no shared understanding of its meaning. This paper published by Diabetes on the Net, critically reviews current research surrounding professional curiosity and discusses the main themes. explores how inter-agency working can promote professional curiosity by supporting healthcare professionals to overcome the complex barriers that may arise during safeguarding cases. It discusses the role of Children and Young People’s diabetes clinics as an ideal platform for utilising the benefits of professional curiosity.
  4. Content Article
    A blog from the Patients Association for World Patient Safety Day on why patient partnership is key to the safe prescribing, supply and taking of medicines. "Being prescribed medication is one of the most common interactions between patient and healthcare professional: this World Patient Safety, let’s ensure all medicine prescribed today is done so following a discussion of its benefits and risks and with the patient’s full participation."
  5. Content Article
    In this blog, Ian Lavery, Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB) summarises a presentation given to HSIB staff by healthcare improvement expert Professor Mary Dixon-Woods. The presentation highlighted that a recommendation alone could fall short of the intended impact on the healthcare system. It looked at creating recommendations to respond to real world working, the importance of involving people most affected by patient safety incidents and why it's vital to look at when things go right.
  6. Content Article
    Patient safety culture is a vital component in ensuring high-quality and safe patient care. This cross-sectional study aimed to assess doctors’ and nurses’ perceptions of patient safety culture in five public general hospitals in Hanoi, Vietnam. The study found that the mean scores among nurses were significantly higher than that among physicians for several categories: supervisor/manager expectations staffing management support for patient safety teamwork across units handoffs and transitions Nurses reported significantly higher patient grades than physicians (75% vs 67.1%) and around two-thirds of physicians and nurses reported no event in the past 12 months (62.8 and 71.7% respectively). The authors recommend that hospitals develop and implement intervention programs to improve patient safety, including around teamwork and communication, encouraging staff to notify incidents and avoiding punitive responses.
  7. Content Article
    In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.
  8. Content Article
    Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients.
  9. Content Article
    Patient safety culture is the foundation of patient safety and refers to a healthcare organisation’s shared values, norms and beliefs that influence staff’s behaviour and actions. This study in BMJ Open Quality aimed to assess nurses’ reporting on the predictors and outcomes of patient safety culture and the differences between patient safety grades and the number of events reported. It aimed to fill a gap in research by looking at patient safety culture in terms of both predictors and outcomes. The author developed a cross-sectional comparative research design and recruited 300 registered nurses to take part in a survey on patient safety culture. The author found that nurses generally perceived patient safety culture as 'moderate', and identified areas that should be prioritised to improve patient safety culture. They concluded that assessing patient safety culture is the first step in improving hospitals’ overall performance and quality of services, and that improving patient safety practices is essential to improving culture and clinical outcomes.
  10. Content Article
    Engaging with company executives over how their decisions affect employees’ performance further down the line could help improve safety at sea. An 18-month study found investigations of maritime accidents tend to “blame the ship”, often resulting in the punishment of seafarers.  Authors Barry Kirwan, Ben Wood and Beatrice Bettignies-Thiebaux of Eurocontrol, argue that this approach hampers learning and more attention needs to be paid to contributory factors from higher up the chain. They say that a deeper understanding of organisational influences and how company culture contributes to accidents will help promote safety across the business and better address problems.  They have developed a ‘Reverse Swiss Cheese Maritime Model’ which moves from organisation through design and fleet support to vessel operations. To facilitate this, they believe there needs to be greater engagement between analysts and the industry’s decision makers and are hoping to trial their approach with several organisations over the next year. Barry, who presented the findings at our recent conference, said: “We need to look not only at how ‘work is done’ but how ‘business is done’.”
  11. Content Article
    Conversations that leaders have with their team members are the drivers of psychological safety. In this blog, Tanmay Vora looks at how to start conversations that build psychological safety in teams. He includes two infographics which highlight suggested conversation starters for team leaders and team members.
  12. Content Article
    Patient safety remains a global challenge for society today; in high income countries, it is estimated that one patient in ten is subject to adverse events while receiving hospital care. This article by Laís Junqueira, Quality, Patient Safety and Innovation Manager at Elsevier, in The Journal of mHealth looks at how enabling safer healthcare decision-making could reduce the burden of avoidable harm. Junqueira highlights the need to recognise that non-analytic and implicit decisions occur in healthcare systems, and that these have an impact on patient safety. He argues that as healthcare systems evolve, there must be an increased focus on the importance of an environment that fosters safe decision-making.
  13. Content Article
    The NHS Patient Safety Strategy aims to monitor and support the development of a strong patient safety culture within the NHS, creating an environment where individuals feel they will be treated fairly and compassionately if they speak up. In this publication, NHS England collates insights from focus groups held with NHS organisations that are rated by the Care Quality Commission as outstanding or good for its ‘Safe’ assessment domain. The insights reflect what they have done to support a patient safety culture within their organisations.
  14. Content Article
    Corey Adams, Researcher at the Australian Institute of Health Innovation, shares the impact of trauma on the patient experience. Corey shares his personal story of trauma and how we can alleviate the negative effects of trauma by building a culture of safety, kindness, trust, and respect.
  15. Content Article
    This framework produced by the Royal College of Paediatrics and Child Health (RCPCH) aims to improve how healthcare organisations recognise and respond to children at risk of deterioration. A safer system can work in partnership with families and patients, develop a patient safety culture and support ongoing learning. The framework covers: Patient safety culture Partnership with families Recognising deterioration Responding to deterioriation Open and consistent learning Education and training
  16. Content Article
    In this study, Aniza Ismail and Norhani Mazrah Khalid assessed the baseline level and mean score of every domain of patient safety culture among healthcare professionals at a cluster hospital in Malaysia and identifed the determinants associated with patient safety culture. The study found that healthcare professionals at the cluster hospital showed unsatisfactory patient safety culture levels. Most of the respondents appreciated their jobs, despite experiencing dissatisfaction with their working conditions. The priority for changes should involve systematic interventions to focus on patient safety training, address the blame culture, improve communication, exchange information about errors and improve working conditions.
  17. Content Article
    Safety conversations are an important step in building a proactive patient safety culture. They’re a respectful discussion about safety between two or more people involved in organising, delivering, and seeking or receiving care. This collection of tools and resources, from quick tip sheets to comprehensive reports and frameworks, aims to help healthcare professionals to have effective safety conversations and support safer care of older adults.
  18. Content Article
    Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. In this blog, he reflects on what he has learned from 25 years as a human factors expert, highlighting that human factors is essentially about improving work, via design.
  19. Content Article
    This download is the second of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students.
  20. Content Article
    The Health and Care Act 2022 will establish the Healthcare Safety Investigations Branch (HSIB) as the Health Services Safety Investigations Body (HSSIB) in April 2023, a fully independent arm’s-length body. This blog by Dr Sean Weaver, Deputy Medical Director at HSIB, outlines what HSSIB's new powers will be.
  21. Content Article
    Preventable harm, from the systems of care intended to improve health, continues to occur at an unacceptable rate in the United States. Healthcare systems have an opportunity to learn and improve from each episode of preventable harm. Accordingly, every preventable patient death or injury must energise our efforts to prevent future patient harm. The Anesthesia Patient Safety Foundation (APSF) believes that criminal prosecution of healthcare providers will make the work of preventing harm more difficult since it continues to shift the focus away from system improvements. They have released a position and policy statement outlining the rationale for opposing criminal prosecution and, equally important, recommends that all healthcare systems and organisations aggressively act, now, to improve their culture, processes, and training to reduce errors of all kinds and, specifically in light of recent events, medication errors. Some specific actions are recommended as examples of what can be done. Individual healthcare professionals should be mindful of their role in preventing errors and reporting errors that occur as well as taking action to encourage and enable their organization to improve the flaws in the systems in which they work that lead to harm to patients.
  22. Content Article
    This programme from the Advancing Quality Alliance (Aqua) provides participants with the tools, skills and knowledge to oversee the successful implementation of a safety culture survey in organisations. Participants of this programme will develop a working knowledge of safety culture theory and the Agency for Healthcare Research and Quality (AHRQ) safety culture survey alongside the support that Aqua provides to enable deployment and analysis of the survey. This programme links directly to Aqua’ safety offers, including Psychological Safety, Human Factors and Improvement Practitioner programmes.
  23. Content Article
    For two decades, Swiss Cheese theory has been an influential metaphor in safety science and accident prevention. It has made barrier theory and the impact of safety culture on operational safety more understandable to the upper echelons of high-risk organisations in many industrial sectors. Yet sometimes the Swiss Cheese model is used to focus on the operational ‘sharp end’ and unsafe acts, like a magnifying glass that acknowledges organizational influence, but still targets the human operator. It is time to ‘turn this lens around and allow organisations to focus on the upstream factors and decision-making that can engender these unsafe acts in the first place. This paper reports on an approach to do this, under development in the Maritime sector, called Reverse Swiss Cheese.
  24. Content Article
    This open access book addresses the future of work and industry by 2040—a core interest for many disciplines inspiring a strong momentum for employment and training within the industrial world. The future of industrial safety in terms of technological risk-management, although of obvious concern to international actors in various industries, has been quite sparsely addressed. This brief reflects the viewpoints of experts who come from different academic disciplines and various sectors such as oil and gas, energy, transportation, and the digital and even the military worlds, as expressed in debates and discussions during a two-day international seminar. 'Managing future challenges for safety' will interest and influence researchers considering the future effects of a number of currently developing technologies and their practitioner counterparts working in industry and regulation.
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